(February 13, 2009 - Insidermedicine) At the American Heart Association's scientific sessions in New Orleans, we spoke with Dr. Christopher Granger, Director of Duke University's Cardiac Care Unit and Professor of Medicine at Duke University Medical Center. Dr. Granger is also Vice Chairman of the American Heart Association's Mission Lifeline Program.
If I had chest pain on and off for a week...

Dr. Granger: Anytime a person has chest pain that's concerning to them--chest discomfort, even other related symptoms like epigastric discomfort, unusual shortness of breath, dizziness, nausea--that patient should seek medical attention. If those symptoms are concerning and last more than about 20 minutes then it's important to call a physician and come see a physician immediately. And the reason for that is that this may represent a heart attack that could be fatal if not treated quickly. If it is treated quickly it can be prevented and patients can do very well.
What should I expect on exam?

Dr. Granger: At the doctors office, the patient will get a detailed history about what the symptoms feel like, an exam to see if the heart sounds are normal and if there's any fluid in the lungs, and very importantly, will get an electrocardiogram (EKG) which will tell whether the patient's having a heart attack or not, and blood work which will also indicate whether the patient may be having a heart attack.
What causes angina, and how is it classified?

Dr. Granger: Angina is caused by an imbalance of the amount of blood supply and oxygen that's getting to the heart muslce, compared to how much the heart muscle needs. And generally, angina is caused by a blockage of the artery, although it can also be caused by spasm of the artery (that, in fact, is generally related to cigarette smoking and underscores another reason it's important not to smoke cigarettes). Also, other conditions can result in angina. But the most concerning cause is inflammation in the blood vessel that causes a rupture of plaque and blood clot that can cause a devastating heart attack but can be prevented, or at least minimized if treated quickly.

What diagnostic tests are ordered?

Dr. Granger: The main diagnostic tests to evaluate chest pain that could represent angina or heart attack include an electrocardiogram and blood work to see if there's evidence of heart damage in the blood stream, as well as a variety of additional tests. There are a number of different stress tests, including a treadmill stress test. And then cardiac angiography, and potentially, a procedure to reestablish blood flow like an angioplasty or stent placement.
How is angina managed?

Dr. Granger: Angina is managed according to, first of all, whether or not upon evaluation it truly does appear to be unstable angina, or, a heart attack. And secondly, about the risk of a patient once they seem to have some type of angina. So usually, if it's more severe chest pain that lasts longer than 20 minutes, then that person will be brought in at least to the emergency department for several hours of observation. And if it turns out that it's a heart attack, then a patient will be admitted to the hospital and generally, will have a cardiac catheterization and revascularization with one of these procedures, if appropriate.

What should be done in terms of lifestyle/behavioral modifications?

Dr. Granger: One of the most important things in prevention. In fact, the best way to deal with chest pain is to prevent the process from occurring. Even after it has started--to prevent its progression. The most important ways to prevent the progression of coronary artery disease include avoiding or stopping cigarette smoking, having cholesterol treated, having blood pressure managed, avoiding the tendency to develop diabetes (which includes exercise and weight control and following blood sugars and being physically active).

What treatments are there for angina?

Dr. Granger: Once a patient has angina, and has, say, a stress test that may show that there is likelihood of a significant blockage, then a patient has a cardiac catheterization, in which a small tube is place in an artery in the leg, or arm, and contrast dye is injected into the arteries that supply the heart muscle with blood to see if there's a blockage. If there is a blockage or a number of blockages, then those can be treated in two different ways (in addition to best medical treatments, and there are excellent medications including cholesterol medications, aspirin, and other medications to control blood pressure and control the process). The procedures to deal with the process include, generally, either a coronary procedure with an angioplasty and usually a coronary stent (a scaffold that keeps the artery open). If there are multiple blockages, especially if the heart muscle is somewhat weakened, then coronary artery bypass surgery is generally a preferred approach.

What medications are used to treat angina?

Dr. Granger: Medications, in fact, are the cornerstone for treatment for patients who have angina and coronary artery disease and they are very important. In fact, we have four or five different types of medication which are proven to prevent death, heart attack and stroke. Being assessed for these medications, which include medications like aspirin and other anti-platelet drugs, cholesterol medicines like statin drugs, and other blood pressure medications like ACE inhibitors, beta blockers, these are all very important drugs for certain groups of patients to prevent the occurrence or progression of heart disease. And one thing that we work very hard on, is working with patients to ensure that they're reliably and systematically taking these drugs. Because, so often, patients end up stopping these types of drugs
Should I be concerned about possible progression to a heart attack?

Dr. Granger: For a person who's at risk for heart disease--and, in fact, because of aging everyone in America is at risk of heart disease--it's very important to recognize the signs that might represent a heart attack. And this is because if a person develops these signs and comes quickly to medical attention, then the heart attack can be minimized or perhaps, prevented. And the most concerning signs for heart attack are the more severe angina symptoms-like chest pain that is fairly severe that lasts for longer than 5 minutes. We used to say, wait 20 minutes and then call 911, but now we say only wait 5 minutes if one is having concerning symptoms of chest discomfort. But then, especially if these symptoms last for longer than 20 minutes and/or are associated with sweating, nausea, fainting, or near fainting--those are the symptoms that we're most concerned about. They may represent a heart attack.
What is the AHA doing about heart attacks?

Dr. Granger: The AHA has taken a leadership role in America in providing the materials and eduaction for people to recognize these symptoms that may represent heart attack. In fact, there's a large program now that the AHA is leading called Mission Lifeline. It aims to help provide a much better national infrastructure for providing rapid and effective care for patients who have heart attack. But it begins with the patient calling for medical help. It's critical for people to understand that if one, or one in one's family, develop chest discomfort that lasts for more than 5 minutes and concerns that person, to call 911. That's really where the trigger begins to provide life saving care.

IN SUMMARY

Dr. Granger: If I had chest discomfort that might represent unstable angina (or, heart attack), what I would want is to call 911 early into the symptoms, within 5-10 minutes of developing symptoms, to be brought to a hospital that could get an EKG and determine whether or not I was having a heart attack, and if not, have a stress test that would determine whether or not I would need further testing (like a cardiac catheterization that might find blockages that could be fixed that would prevent me from having further problems.)